Poverty Is Largely Invisible Among College Students

The first time I met an undergraduate who hadn’t eaten in two days, I was stunned. The first time I spent the afternoon with a homeless college junior, I cried for most of the night. Now, after a decade of research on food and housing insecurity among college students, I’m just numb.

I teach at an urban public university—a “Research 1,” top-of-the-Carnegie-rankings institution. I’m not one of Philadelphia’s school teachers; I’m a professor with just one class to teach each term and a big research budget. But those trappings of prestige no longer shield me from the realities of poverty in our city, and more importantly, they don’t help my students.

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Since 2008, my team’s research on how students finance college has revealed that the main barrier to degree completion isn’t tuition; it’s having a place to sleep and enough food to eat. The best estimates suggest that food insecurity affects as many as 1 in 2 college students—much higher than the rate in the general population. Just as many struggle with housing insecurity, and a significant number (14 percent at community colleges) are homeless.

This is a largely invisible problem. Stereotypes of Ramen-noodle diets and couch-surfing partiers prevent us from seeing it. They trick us into thinking that food insecurity is a rite of passage, that hunger and even homelessness among our students is normal. But it is time to admit that we have a serious problem in higher education.

Some campuses have begun implementing small reforms to address food insecurity. The College and University Food Bank Alliance has more than 525 members from coast to coast, with food pantries housed at community colleges and universities, public and private. This is a stunning increase, since in 2012 there were just over 10. That provides emergency assistance to the students who are lucky enough to know about them, though what they actually stock varies. Sometimes there are fresh fruits and vegetables, but usually there are cans and bags, some bread, and the occasional bottle of shampoo or body wash.

In some cases, colleges are moving beyond food pantries. Just over two dozen schools operate a program known as Swipe Out Hunger, which reallocates unused dollars on meal plans to students who need them. Homegrown efforts such as Single Stop are helping students apply for SNAP, and some institutions are beginning to accept EBT on campus. In Houston, the local food bank is offering “food scholarships” to community college students, proactively providing groceries rather than waiting for emergencies to occur. There are food recovery networks, nutrition programs, and educational activities like Challah for Hunger, where students gather to break bread and learn about poverty. These efforts are entry points to systemic change, and they make it possible to envision a time in which the National School Lunch Program operates on all campuses, providing breakfast and lunch to every student who needs it.

Stereotypes of Ramen-noodle diets and couch-surfing partiers prevent us from seeing it.

But when it comes to housing, things don’t look so good. When colleges and universities think about housing, they see dollar signs to be gained from residence halls catering to wealthy and international students, rather than opportunities to facilitate affordable living. Given massive state disinvestment throughout the country, it is hard to blame the public institutions. But it means that a growing number of students are being left out in the cold.

Students who struggle to pay rent are at risk of eviction, like so many other low-income adults around the country. Those who seek out shelters find the same overcrowded and sometimes dangerous conditions that have long plagued those temporary accommodations, and students often miss out on beds because the lines form while they are still in class. Even young people who grew up in public housing can lose their housing when they enroll in college if their local housing authority deprioritizes full-time undergraduates.

The financial aid system contributes to these problems. Consider a 23-year-old adult living on the streets, estranged from two middle-class parents because he is queer. Under federal law, his parents’ income is used to determine his financial aid, even though he lacks access to those resources. His only hope of disregarding their income and qualifying for more support is to endure a “special circumstances” process that requires documentation verifying that he is homeless, which can be challenging if he was not homeless in high school and is not in the shelter system. In 2015-16, nearly 32,000 college students completed the Free Application for Federal Student Aid (FAFSA) verification process and were officially deemed homeless for financial aid purposes. However, more than 150,000 students indicated that they were homeless on an initial filtering question, but could not complete the necessary documentation process.

The oversight of the very real housing and food needs of undergraduates is hypocritical given the intense pressure we place on people today to complete college degrees. It is very difficult to complete anything—whether it is a vocational training program for a welding certificate, an associate’s degree in nursing, or an engineering program—without first having your basic needs met.

I am trying, in my own way, to do what I can. Last year, I created the FAST Fund to provide students with cash, quickly, when it is needed. And I added a statement to my syllabus that will remain there indefinitely:

Any student who has difficulty affording groceries or accessing sufficient food to eat every day or who lacks a safe and stable place to live, and believes this may affect their performance in the course, is urged to contact the CARE Team in the Dean of Students Office for support. Furthermore, please notify me if you are comfortable in doing so. This will enable me to provide any other resources that I may possess.

It is but a start, meant to help establish a culture of care in my classroom, one that I hope can be transmitted and reflected throughout the university. We can and must go further. Every college and university must help its students connect to every public benefits program for which they are eligible. That support, coupled with emergency cash assistance, can help shield students from hunger and help them keep a roof over their heads. Colleges should also pursue external partnerships with local food banks, housing authorities, and homeless shelters. And most of all, higher education has a responsibility to tackle poverty among its students in a data-driven way that acknowledges that students without resources do not lack talent, drive, or intellect. They simply need access to the same sorts of supports that students from families with money enjoy every day.

Talk about social mobility is all the rage in higher education right now. But let’s get real: College is a great route out of poverty, but for that path to work students must escape the conditions of poverty long enough to complete their degrees.

Meet the Congresswoman Trying to Remove Barriers to Opportunity for People with Records

Ex-offender Ronald Birkmire Jr. is seen at work in Philadelphia, Thursday, May 1, 2008. (AP/Matt Rourke)

Today, as many as 1 in 3 Americans have some type of criminal record—many convicted of only minor offenses, and some having only arrests that never led to a conviction. But even a minor record can create lifelong barriers to employment, housing, education, and more, relegating many people with records and their families to a lifetime in poverty.

That’s why a bipartisan coalition in Pennsylvania has worked for more than two years to pass first-in-the-nation “clean slate” legislation that would allow minor nonviolent records to be automatically sealed once an individual remains crime-free for a set period of time. A bill was unanimously approved in the Pennsylvania Senate, 50-0, earlier this year, and it is expected to clear the House soon. Gov. Tom Wolf (D) has said he will sign the legislation into law. Even the Philadelphia Eagles are vocally supporting the bill.

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And now there is movement to bring clean slate to the halls of Congress. At the recent #UnlockingOpportunity conference in Washington, I spoke with Rep. Lisa Blunt Rochester (D)—Delaware’s first woman and first person of color elected to Congress—about her run for office and the prospect of clean legislation at the federal level.

Rebecca Vallas: I’d love to hear from you about your background and why you’ve decided to take on criminal justice reform and re-entry.

Rep. Lisa Blunt Rochester: First, I never ran for office in my life. But in 2014, my husband ruptured his Achilles tendon on a business trip and blood clots went to his heart and lungs and he passed away. It changed everything for me.

I’m typically a very joyful person. Every job I’ve ever had I brought joy to it—from working as a summer youth employment coordinator, to working in the office of then-Congressman Tom Carper as an intern, to being a case worker and working on Social Security Disability and housing and other issues, to being Delaware’s secretary of labor. But when Charles passed, it made me question why am I here. What’s my purpose? And that election year I saw so many people who looked either sad or mad, who had a feeling of loss. Whether they lost their job or home during the housing crisis, or a child to gun violence, it just felt heavy. And the people who were running for office … I was like, “I’m already sad, and y’all are bringing me down.”

One or two encounters with the law should not stop you from supporting yourself or your family.

So, I decided to run. And I was debating Ivy League lawyers. People would comment on blogs that I looked like a deer in the headlights—because I was a deer in the headlights, I was scared to death. But the more stories I heard from people in my state, the more compelled I felt. And I remember one day at a campaign event in the park a guy was talking about the fact that he had gotten out of prison, and no matter how hard he tried he could not find a job. It reminded me of my own family history—my uncles and cousins in Philadelphia who went in and out of the prison system. And so this whole concept of clean slate rang true because your one or two encounters with the law should not stop you from supporting yourself or your family. This issue touches people’s ability to buy a home, to rent an apartment, to just live.

When I heard about Pennsylvania’s legislation, it was a no-brainer for me that this is an issue that cuts across parties. And so we can announce here that I will be introducing federal clean slate legislation.

RV: Thank you. And I’d love to hear from you how a federal clean slate law could remove barriers not just for people with records but for their children and for their families.

LBR: We all know the impact that a parent going through a criminal justice system has on families. An article in The Atlantic magazine is a perfect example. It’s about a woman who was 57 years old, who was a grandmother. This charge had been following her for 38 years and stopping her from getting a job. But this legislation is saying it shouldn’t be hard for you to clean your record when you’ve served your time, some time has gone by, and it was a nonviolent offense. Anything that gets rid of the barriers for people to live, go to school, have a job, rent or own a home, that’s the goal of this legislation is to clean the slate so that you can live your life.

RV: What are the chances of seeing something actually move through Congress?

LBR: We can at least try to find common ground. I already have in mind a [Congressperson] who’s got a criminal justice background, who will probably seem way to the other political extreme of me, but who can also provide credibility. I believe that we can get this done—and it doesn’t even cost money. The fact that it could possibly save money and help the economy and help people’s lives I think makes it a win-win-win.

I also want to leave everyone with a message of encouragement. That no matter what you see swirling around you, stay focused. I was a dancer as a kid, and we’d do pirouettes. And people would say, “How can you spin and not fall?” It’s because you would focus on one spot, even though everything is spinning around you. We’re gonna make it through all of this swirl.

The Most Horrifying Provisions Hidden in the House Republican Tax Plan

President Donald Trump kisses a printed example of what a new tax form may look like during a meeting on tax policy with Republican lawmakers in the Cabinet Room of the White House, Thursday, Nov. 2, 2017, in Washington, as House Speaker Paul Ryan (R-WI) and chairman of the House Ways and Means Committee Rep. Kevin Brady (R-TX), watch. (AP/Evan Vucci)

Yesterday, House Republicans released their tax plan, finally providing long-awaited details on what they really mean when they promise “tax reform.” While they billed it as a middle-class tax cut, the new legislation is filled with gifts for wealthy corporations and the richest Americans. Meanwhile, middle-class and working families would at best get scraps—and in many cases, see their taxes increase.

Many of the most extreme tax increases come in the form of eliminated tax credits or deductions buried deep in the text of the bill—and ignored by lawmakers and the media. With tax increases affecting groups ranging from seniors and people with disabilities, to families facing costly medical bills, to immigrant children, to people with student loans—to name just a few—the bill is a virtual laundry list of tax increases on populations who are often struggling to make ends meet.

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Here are eight of the most horrifying provisions buried in the tax plan.

1. It raises taxes for people with student loans

Americans now owe more than $1.4 trillion in student loan debt—nearly double all credit card debt. The average monthly payment is up to $351 (or more than $4,200 a year) for borrowers between the ages of 20 and 30—a large chunk of income for young Americans.

Thankfully, under current law, borrowers can deduct up to $2,500 of the interest on these loans per year, which helped more than 12 million Americans in 2015. But the House tax plan eliminates that deduction. If the plan passes, the average borrower will see their taxes go up by $275 each year just on student loan interest. And a borrower who pays the full $2,500 in interest would see their taxes go up even more—by a whopping $625.

2. It raises taxes on people facing high medical expenses

Under current law, people are able to deduct medical expenses that exceed 10 percent of their income for the year. This benefits thousands of people facing serious illnesses or with long-term care needs—and gives them some financial relief in the face of high medical bills.

But the House Republican plan eliminates that deduction, too. This will hit people with disabilities as well as elderly nursing home residents particularly hard, as they often pay tens of thousands of dollars in out-of-pocket costs for long-term care. Much like their earlier plan to repeal the Affordable Care Act, the change is also aimed directly at states that supported Donald Trump in the 2016 election, where residents are more likely to be uninsured and have higher medical costs.

3. It ends a tax credit that helps parents adopt

For thousands of adoptive parents, adoption is only possible because of the adoption tax credit, which helps parents recoup up to $13,000 of the cost of adoption. House Republicans would eliminate the adoption tax credit, making it harder for countless would-be parents to have children. There are more than 100,000 children in U.S. foster care today (not to mention millions more orphaned or abandoned), and eliminating the credit would make it significantly harder for them to find a permanent home.

4. It makes disability accessibility more expensive for small businesses

Under current law, small businesses can claim a tax credit to offset 50 percent of the cost of accessibility for people with disabilities for expenses between $250 and $10,250. But the House GOP tax bill would eliminate that tax credit, effectively raising taxes on small businesses trying to make sure their doors are open to people with disabilities. This comes as legislation currently pending in the House—misleadingly titled the “ADA Education and Reform Act of 2017”—would gut the very part of the Americans with Disabilities Act that requires public places to ensure accessibility for people with disabilities.

5. It eliminates a tax credit that spurs investment in poor communities

Trump has repeatedly promised to save and bring back jobs in communities left behind. But the House Republican tax bill would eliminate a tax credit that encourages businesses to invest in hard-hit rural and urban areas. Investors who qualify for the New Markets Tax Credit get a tax credit to partially offset their investments in distressed communities where the poverty rate is 20 percent or higher. The vast majority of the tax credit’s funding has benefited communities with unemployment rates more than 1.5 times the national average and/or poverty rates of at least 30 percent.

6. It allows churches to be manipulated for political purposes

Under current law, 501(c)3 nonprofit organizations—including churches—are prohibited from endorsing or opposing political candidates. Trump has long made known his desire to repeal this policy, known as the Johnson Amendment—as far back as the early 2000s, as well as throughout his presidential campaign—claiming it violates churches’ First Amendment rights. And hidden in the House GOP tax bill is a provision that would make good on Trump’s promise, despite the fact that nearly 80 percent of Americans say they do not support political endorsements in church. As a letter from more than 4,000 faith leaders opposing this change states: “Faith leaders are called to speak truth to power, and we cannot do so if we are merely cogs in partisan political machines.”

Buried in House Republicans’ tax bill is their latest effort to advance the GOP’s anti-choice agenda

7. It takes away critical income from immigrant families with kids

While House Republicans are busy patting themselves on the back for including modest enhancements to the Child Tax Credit (CTC) in their tax bill, they have changed the credit so that many immigrant families with citizen children will not be able to receive it. The bill would require all filers to provide a Social Security number, instead of an Individual Tax Identification Number, which immigrant workers with qualifying citizen children can currently use to claim the credit. According to the nonpartisan Institute on Taxation and Economic Policy, more than 5.1 million children of immigrant parents would lose access to the CTC under this provision.

8. It gives fetuses legal status as people

Buried in House Republicans’ tax bill is their latest effort to advance the GOP’s anti-choice agenda. Specifically, they use a provision in the bill that would allow parents to buy 529 college savings plans for unborn children as a smoke screen to, yet again, try to give fetuses legal status as people. The provision goes out of its way to define unborn child as a “child in utero … a member of the species homo sapiens, at any stage of development, who is carried in the womb.” This comes on the heels of Trump’s Department of Health and Human Services’ strategic plan draft released last month, which bent over backwards to define life as beginning at conception.

The House Tax Plan Would Make It Impossible For Me to Have Kids

House Ways and Means Committee Chairman Kevin Brady (R-TX), joined by Speaker of the House Paul Ryan (R-WI), right, discusses the GOP's far-reaching tax overhaul, the first major revamp of the tax system in three decades, on Capitol Hill in Washington, Thursday, Nov. 2, 2017. (AP/J. Scott Applewhite)

Yesterday, Congressional Republicans released their new tax plan. The New York Times picked it up early, with a headline announcing that it focuses on “cutting corporate and middle-class taxes.” When I saw it, I couldn’t help myself—I actually thought, “Hey, I’m middle-class.” So I clicked the link.

That brief moment of optimism—the hope that maybe, just maybe, House Republicans had done something that would help me—didn’t last long. Turns out they aren’t particularly worried about this middle-class lady. The dreams I’ve held closest to me—the ones I want so desperately that I can barely even admit them to myself—could be completely dashed by this plan.

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My wife doesn’t dream in secret like I do. She’s pretty transparent. And what she wants, more than anything, is to be a parent.

Deep down, she’s a dad. She thinks instructions are for quitters, she plays air guitar while she dances, and she laughs—hard—at her own jokes. She asks me every time she puts on sunglasses if she looks “like a cool kid,” and I once watched her use finger guns as an earnest form of praise for someone who had just finished a particularly difficult parking job. (It was on our wedding day. I married her anyway.)

I always thought of her weird-dad behavior as an eccentricity. It’s sweet that she manages our budget for fun, that she wants to be the house with the best candy on Halloween, and that she’ll spend an entire dinner party trying to hang a friend’s bike rack. But this year, something started to shift. She started to really want a baby to go with all of those paternal affectations.

At first she’d just make faces at little kids that were staring her down. Then she started to get wistful any time she saw a baby with unruly hair. And earlier this week, she came home from the grocery store yelling that we needed to move because our house barely got any trick-or-treaters, but there were dozens of little kids in costumes just two blocks up.

I always knew in the back of my mind that this was going to happen. I was ambivalent about kids, but I could tell—even when she swore it wasn’t true—that my wife needs to be a parent. So, we started to factor those imaginary future kids into our choices. We bought a little house with too many bedrooms in a good school district. We got a car with extra room in the back, and a dog with a particular soft spot for babies.

This summer, I started to feel it, too. It snuck up on me—I was sitting on my sofa, laptop in my lap, and I suddenly found myself wishing that there was a sleeping infant on my chest. I texted my wife and told her I was ready to adopt.

That’s just the first step in a years-long process. When you’re queer, having a baby is complicated. Just finding one—whether you’re looking for raw ingredients or a finished product—is extremely expensive. But there are actually breaks written into the tax code that help us out: little gifts from a government that has spent generations marginalizing families like ours. Need in vitro fertilization to conceive with your donor sperm? You can deduct some of the medical expenses from your tax bill. Plan to adopt? There’s a sizable credit to make it affordable.

The deductions and credits that would have made it possible for me to have a child? They’re gone.

Except, now there isn’t. The House Republican tax plan is filled with delicious treats for the wealthy: repealing the estate tax, cutting corporate tax rates, and notching down the top income tax rate. And to help pay for it, Congressional Republicans have cobbled together a list of credits to eliminate so obscenely cruel it would make Ayn Rand blush. The credits for individuals over 65 or who are retired on disability are gone, and the deduction for teachers—the one that helped me afford all the pencils and notebooks I bought for my students when I worked in public schools—has vanished. The deduction for paying high local taxes—like the ones my wife and I pay in order to live in that good school district—has been whittled away.

And the deductions and credits that would have made it possible for me to afford having a child? They’re gone, too.

Without those deductions and credits, my wife and I won’t be able to have children. We cannot afford the upfront cost of adopting or conceiving, combined with the costs of preparing to bring a child into our home and the child care we would need for the next several years. We’ve done the math—by the time we scrape the money together, we’ll be too old for most adoption agencies to consider us and it’s unlikely we’ll be able to conceive.

And so, with a single tax bill, House Republicans have denied the love of my life the chance to have the family she desperately wants. And they’ve done it so the loves of their lives—corporations and the ultra-rich—can have something they don’t even need.

The Cost of Addiction Treatment Keeps Poor People Addicted

People wait in line for the Evergreen Treatment Services methadone clinic to open in Hoquiam, Wash., Thursday, June 15, 2017. (AP/David Goldman)

I can barely remember the day I learned I was pregnant with my first daughter. Not because I was overwhelmed with emotions, but because I was high on heroin. I had been addicted for five years, and I had been trying to rid myself of that addiction for almost as long. I‘ve lost count of how many times I detoxed during that time. I just know that, even when I managed to make it through the week of withdrawal, I inevitably relapsed.

By the time I learned I was pregnant, I knew abstinence didn’t work. I also knew I had to do something if I wanted to have a healthy baby. So, I enrolled in methadone maintenance treatment. My doctor insisted on it—he told me it would keep my body from going through withdrawal, which could have caused a miscarriage. But I almost couldn’t afford it. I was in Colorado, one of 17 states that did not cover methadone through Medicaid or state funds. Luckily, I was able to get my treatment paid for through grant money specifically designated for pregnant methadone patients.

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Because of that grant, I never had to worry about the cost of my treatment. I was able to stand to the side and watch while other patients came into the clinic, begging for an extra couple days to come up with their fee, only to receive the same response from the receptionist: “You could get together money for your drugs, why are you having a problem getting money for treatment?”

I lost count of how many times I heard her say that.

Approximately 2 million people in the United States are addicted to pharmaceutical opiates, and half a million to heroin. The latest report from the Centers for Disease Control and Prevention estimates more than 60,000 overdose deaths in the United States last year. Opioids are now more fatal than car crashes and gun violence. And those numbers don’t include the many people who survive but live with complications such as brain damage for the rest of their lives.

Your brain thinks it’s dying without the drug.

Despite the broad scope of the crisis, data compiled by Rockefeller University’s Addictive Diseases lab show that there are only about 350,000 Americans in methadone treatment, a long-acting
opioid agonistAn agonist is a chemical that binds to receptors and causes a biological response (in the case of opioids, that response is pain relief). Methadone is an opioid agonist that causes a similar biological reaction to opioids without the euphoric high, preventing the severe physical symptoms of withdrawal.
that has historically been the gold standard of care for opioid addiction. Only about 75,000 are in buprenorphine treatment, a newer alternative that is similar to methadone in function and purpose.

There are some basic reasons that so few people receive treatment: More than 30 million people live in counties without a licensed provider of buprenorphine, and the daily process of receiving methadone maintenance treatment at a specialized clinic is incredibly time consuming.

And it’s expensive.

In addition to the limits on Medicaid funding, opioid treatment providers can decide whether or not to accept private insurance. Many decide against it, or contract with just one or two providers, because methadone treatment is difficult to translate into insurance billing terms. Every state provides coverage for buprenorphine/naloxone (naloxone is an additive that prevents abuse of the drug), but patients often have to find cash for treatment regardless of whether the medication itself is covered.

The National Institute on Drug Abuse estimates that the per-patient cost of methadone for providers is $4,700 yearly, but for-profit opioid treatment programs get to decide what they charge their patients. This means the actual cost to patients varies by clinic. Methadone patients I interviewed reported rates that ranged from $350 per month to $200 per week. Buprenorphine patients reported clinic costs between $100 and $300 per month, with medication costs broaching the thousands for those without insurance.

Zac Talbott owns two opioid treatment programs—one in Georgia and one in North Carolina—and is also a methadone patient (through a different provider). He explains to me over the phone that just because Medicaid covers methadone in a certain state, that does not mean the clinics actually accept it. Take Georgia, for example: Although Medicaid has covered methadone for several years, programs that were not directly affiliated with behavioral health entities could not bill Medicaid prior to 2016. Only two clinics met that standard, out of 62 in the state. The rules recently changed, and Talbott’s Georgia clinic, Counseling Solutions Treatment Centers, is now six months into the process of setting up Medicaid billing. He’s unsure how many other area clinics will actually take on the new insurance option.

“[Opioid treatment programs] don’t speak in insurance terms the way the rest of health care does. Insurance bills based on codes. There’s no code for a daily bundled rate,” he explains, referring to the daily or weekly flat-rate most clinics charge their patients.

“For a lot of the bigger corporate entities, it’s easier and more profitable to just take that cash, baby,” Talbott adds, punctuating his point with a morose chuckle.

Patients who struggle to find the money for treatment may live with the threat of an administrative detox hanging over their heads. This is a common technique practiced by many methadone clinics, in which a patient who is no longer able to pay is placed on a rapidly tapering dose to wean him off the medication. The length of these tapers varies by clinic, but they often mean going down by 10mg a day, usually with one- or two-month limits. That’s a far cry from the slow, medically supervised taper recommended for patients choosing to withdraw from treatment.

Medication-assisted treatment is designed for long-term use—sometimes even lifelong. Mary Jeanne Kreek, who was part of the team that developed methadone treatment, explains that methadone and buprenorphine help correct brain changes that may require years of maintenance.

“It’s just like treating depressive disorders. Most people on chronic antidepressants need those for a long time or life,” says Kreek. “I think they’re very analogous.”

But even these administrative detoxes are less harsh than what patients face at clinics that simply cut them off. Because methadone is designed to remain stable in the body for long periods of time, withdrawal from a therapeutic dose may take up to a week to begin. Once it does, however, it is nearly unbearable. It’s not necessarily the sweats and cold chills, aching bones, diarrhea, racing heart, nausea, and restless legs that make it so difficult. It’s the fact that your brain thinks it’s dying without the drug. That is part of the reason relapse rates after opioid detoxification are so high—some estimates say 88 percent within three years, and up to 70 percent within six months.

Liz Hock Clark, a 59-year-old woman who has been on methadone for 34 years, says her clinic is one of many that simply ceases to dose patients who come in without payment in hand. She isn’t sure if it’s legal, but she’s seen it done, and she’s terrified it will happen to her.

Clark lives in a small apartment in West Virginia. She doesn’t have much furniture, and there’s no internet connection. If she needs to go online, she hops into her beat up 2000 Chevrolet Cavalier and drives to her cousin’s house. She picks up odd jobs, like house cleaning and dog walking, in order to pay for her medication. She does janitorial maintenance for her building in exchange for rent on the apartment. It’s tough on her body, but it allows her to put every penny she makes into methadone. Her clinic charges $15.50 a day. She says when she started methadone 34 years ago in Texas, it was $2 a day. She is terrified of the day when she doesn’t have the money for her clinic, which she fears will be soon.

“I’m not afraid of relapse,” she explains in her soft Southern drawl. “I’m afraid of dying. For someone my age, going cold turkey off 118 milligrams, I don’t know if I’d survive.”

Death from opioid withdrawal is rare, but because of her age, complications like cardiac arrest from a harsh detox are a credible fear.

“The thing is,” she adds wistfully, “I don’t want to get off methadone. I want to stay on it my whole life.”

How do we help patients like Clark access these essential medications without becoming enslaved by the exploitative tactics of some providers? For starters, the burden of methadone and buprenorphine regulations needs to fall on providers rather than patients. And we need to have a lot more payment options for low-income people, who are already more vulnerable to addiction in the first place.

The preliminary report offered by the White House opioid commission asks for expansion of access to medication-assisted treatment. It does not, however, express the need for a mandate on clinics to accept Medicaid, or for any kind of internal restructuring that will make accepting Medicaid and other forms of insurance more attractive to clinics. Trump’s attitude during his recent public health emergency declaration does not leave much hope that the commission’s advice will be followed—his $57,000 allocation will not come close to covering the cost gap. We’ll need to do a lot more if we are going to serve Clark and other patients like her—or like me—before it’s too late.